Treatment recommendations differ in a third of cases

In a study of patients with multivessel coronary artery disease (CAD), heart team treatment recommendations conflicted with those of original treating interventional cardiologist in almost a third of cases, researchers found.

Michael B. Tsang, MD, MSc, Department of Medicine, McMaster University, St. Catharines, Ontario, Canada, and colleagues determined that in this subset of patients, unanimous agreement among the heart teams occurred at a low frequency and concordance was low between interventional cardiologists.

The study was published in JAMA Network Open: Cardiology.

As pointed out by Tsang and colleagues, the heart team model — usually consisting of an interventional cardiologist, a cardiovascular surgeon, and a noninvasive cardiologist — has been given the highest level of recommendation by the American College of Cardiology/American Heart Association guidelines for treatment decision making in patients with complex multivessel CAD. “Although, to our knowledge, no randomized clinical trials have been conducted to evaluate the benefits of the heart team approach with regard to decision-making or outcomes, observational data suggest that heart team-derived management decisions are safe, and the implementation of heart team decision-making is associated with improvements in patient outcomes,” they wrote.

However, they noted that the rate at which treatment decisions differ between heart teams and the original treating interventional cardiology is unknown. Therefore, in this study, Tsang and colleagues examined the difference between the heart team and the original treating interventional cardiologist in treatment assessments of multivessel CAD patients.

This cross-sectional study included 245 consecutive patients with multivessel CAD who were recruited from a high-volume tertiary care referral center, with a total of 237 patients included in the final virtual heart team analysis. The treatment decisions, which included coronary artery bypass grafting, percutaneous coronary intervention, and medication therapy, were made by the original treating interventional cardiologists between March 15, 2012, and October 20, 2014. These decisions were compared with pooled-majority treatment decisions made by eight blinded three-member heart teams — each containing an interventional cardiologist, a cardiovascular surgeon, and a noninvasive cardiologist — using structured online case presentations.

Tsang and colleagues found that there were 71 cases (30.3%) in which treatment decisions between the heart team and the original treating interventional cardiologist differed. The greatest difference was in treatment recommendations for percutaneous coronary intervention (45.1% of patients received a different treatment recommendation from the heart team than the original treating interventional cardiologist), followed by medication therapy (40%), and coronary artery bypass grafting (22.3%).

The heart team decision was more frequently unanimous when it concurred with the decision of the original treating interventional cardiologist (66.9%) compared to when there was discordance (39.4%). And the heart team’s interventional cardiologist appeared to play a key role in whether the heart team’s treatment decision was in accordance with that of the original treating interventional cardiologists. According to Tsang and colleagues, when the heart team agreed with the original treatment decision, the decision of the heart team interventional cardiologist was in agreement with that of the original treating interventional cardiologist in 84.7% of cases, compared to just 19.7% of cases when the heart team disagreed with the original treatment decision.

The study’s findings — specifically that treatment recommended by the heart team differed from that of the original treating interventional cardiologist in about one-third of cases – “has important practical implications,” wrote Tsang and colleagues. “If heart team recommendations were found to be associated with improvements in outcomes, there may be a subset of patients for whom the heart team approach would be most beneficial. Given the extensive resources required for heart team implementation, selection for this subset of patients may maximize heart team efficiency.”

In a commentary accompanying the study, James C. Blankenship, MD, MAcc, Geisinger Medical Center, Danville, Pennsylvania, and Nestor Mercado, MD, PhD, University of New Mexico, Albuquerque, wrote that one of the study’s important findings is that an asymmetric virtual heart team approach is feasible, and that members of the team were able to come to agreement without the need for face-to-face interaction.

“These asynchronous assessments may provide a faster decision-making process for busy clinicians who find it difficult to schedule face-to-face meetings, and they may become the new normal in the post–COVID-19 virus era,” suggested Blankenship and Mercado.

  1. Heart team treatment assessments of patients with multivessel coronary artery disease will differ from the original clinical assessment of interventional cardiologists in almost one-third of cases.

  2. Further research is needed to determine whether the heart team approach results in better patient outcomes and, if so, which subset of patients receives the most benefit.

Michael Bassett, Contributing Writer, BreakingMED™

Tsang reported receiving grants from the Hamilton Health Sciences New Investigator Fund during the conduct of the study and serving as the codirector of the Hamilton Health Sciences Regional Heart Team Rounds outside the submitted work.

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